JOURNAL CLUB: Structured Radiology Reports Are More Complete and More Effective Than Unstructured Reports
JOURNAL CLUB: Structured Radiology Reports Are More Complete and More Effective Than Unstructured Reports
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DOI：
10.2214/ajr.14.12636
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发表时间：
2014-12-01
影响因子：
5
通讯作者：
Taylor, George A.
中科院分区：
文献类型：
--
作者：
Marcovici, Peter A.;Taylor, George A.
OBJECTIVE.放射学报告是沟通影像学发现的主要方法。传统的自由文本（即，非结构化的）放射学报告需要以意识流的方式口述。结构化报告旨在标准化报告中使用的格式和词汇。这种标准化可以改善调查结果的交流，便于阅读和理解。在审查案件时，结构化报告模板也可用作核对清单，这可能有助于集中注意力和进行分析。本研究的目的是比较非结构化和结构化报告的完整性和有效性。放射科受训人员接受了关于报告背景的教育讲座，并获得了用于口述胸部X光片的结构化报告模板。12名受训人员完成了研究。干预前的60份报告和干预后的60份报告均由四名设盲的医生评分员对完整性和有效性进行独立评分。结果。发现结构化报告在统计学上比非结构化报告更完整、更有效（平均完整性评分，4.42 vs 3.99，p < 0.001;平均有效性评分，4.11 vs 3.85，p < 0.001）。计算每份报告的综合评分，结构化报告的综合评分更高（平均综合评分，8.54 vs 7.83，p < 0.001）。结构化胸片报告比非结构化胸片报告更完整、更有效。虽然需要更多的研究进行验证，这项研究表明，结构化报告可能代表了放射科医生的报告方法的改进。
OBJECTIVE. The radiology report serves as the primary method of communication about imaging findings. Traditional free-text (i.e., unstructured) radiology reporting entails dictating in a stream-of-consciousness manner. Structured reporting aims to standardize the format and lexicon used in reports. This standardization may improve the communication of findings, allowing ease of reading and comprehension. A structured reporting template may also be used as a checklist while reviewing a case, which may facilitate focused attention and analysis. The goal of this study was to compare unstructured and structured reports in terms of their completeness and effectiveness.MATERIALS AND METHODS. Radiology trainees were given an educational lecture on the background of reporting and were provided with a structured reporting template for dictating chest radiographs. Twelve trainees completed the study. Sixty reports from before and 60 reports from after the intervention were each independently scored by four blinded physician raters for completeness and effectiveness.RESULTS. Structured reports were found to be statistically significantly more complete and more effective than unstructured reports (mean completeness score, 4.42 vs 3.99, p < 0.001; mean effectiveness score, 4.11 vs 3.85, p < 0.001). A combined score was calculated for each report and was higher for the structured reports (mean combined score, 8.54 vs 7.83, p < 0.001).CONCLUSION. Structured chest radiograph reports were more complete and more effective than unstructured chest radiograph reports. Although additional studies are needed for validation, this study suggests that structured reporting may represent an improved reporting method for radiologists.